Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 10
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 10-01-13 and 12-31-13 Date of Report: 02-18-14 Page: 1
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 82 88 59.522213 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 82 88 59.522213 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 1.033333 $14.8400 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 1.033333 $19.0700 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 1.033333 $10.3500 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 1.033333 $8.6900 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 4 4 1.033333 $8.0100 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 1.033333 $21.7000 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 1.033333 $64.7200 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 1.033333 $22.7500 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 26 27 172.300001 $10338.0100 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.844444 $97.1100 $114.9900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 28 29 13.288890 $644.5200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 3 1.488889 $72.2100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 26 27 15.611113 $757.1500 $48.5000
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Subtotal (Total Children Is Unduplicated) 77 119 211.800001 $12079.1200 $57.0300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 1.033333 $5166.5000 $4999.8400
AUD -HA_FUP AUDIOLOGY SERVICES 2 3 5.226985 $261.3500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 131 162 114.155958 $5707.8300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 265 291 235.546031 $11777.3000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 150 175 129.477769 $6473.8500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 147 170 146.811100 $7340.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 397 462 346.616647 $17330.7400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 8 56.400000 $1410.0000 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 387 544 4668.083321 $233404.1100 $50.0000
INTR -INTR INTERPRETER 3 4 28.755555 $1437.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 128 165 988.874605 $67124.8200 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 139 177 898.105552 $60963.3800 $67.8800
SENS -V5264 EARMOLD 2 2 2.622222 $47.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 266 348 2105.019040 $142888.6400 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 12.266667 $161.9200 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 7.866667 $786.6700 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1214 2169 15431.209518 $154312.0900 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 49 55 696.992064 $348.5000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 9.200000 $460.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1419 4745 25886.229701 $717488.9900 $27.7200
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Total 4952 26157.551915 $729568.1100 $27.8900
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Number of Children (Unduplicated) With at Least One Authorization 1497